Increased risk of bleeding during and after HoLEP in patients with prostate cancer: A multicentre comparative cohort study

Objective: To assess the frequency and severity of bleeding complications during and after Holmium Laser Enucleation of the Prostate (HoLEP) in patients with prostate cancer, and compare outcomes to a control group of patients without prostate cancer but with similar baseline characteristics. Methods: This multicentre retrospective study included 175 consecutive patients undergoing HoLEP across 3 referral centres with a diagnosis of prostate cancer-128 with known cancer prior to surgery and 47 with incidental findings on postoperative histology. These patients were compared to 500 consecutive control patients without prostate cancer but matched for prostate volume, age, presence of indwelling catheter, comorbidities and anticoagulant/antiplatelet therapy status. Bleeding-related events analysed included intraoperative estimated blood loss, need for transfusion, clot retention, postoperative irrigation, reoperation for haemorrhage and hospital readmission within 30 days. Results: The PCa group experienced significantly higher rates of intraoperative bleeding requiring intensified coagulation (18.3% vs 8.6%, p < 0.01), transfusion (6.3% vs 2.0%, p = 0.02) and clot retention (4.0% vs 1.4%, p = 0.04) compared to controls. Among patients with known PCa, 25.0% experienced bleeding-related complications, while the rate was 14.9% among those with incidental PCa. Patients with a known diagnosis showed higher bleeding risk than incidental cases. In multivariate analysis, both prostate cancer and anticoagulant therapy were independently associated with increased risk of bleeding complications. Antithrombotic/antiplatelet therapy significantly raised the likelihood of bleeding events (adjusted OR 2.8, 95% CI 1.6-4.7; p < 0.001), as did the presence of prostate cancer (adjusted OR 2.1, 95% CI 1.3-3.6; p = 0.004). Patients with both risk factors experienced the highest rate of bleeding (29.4%), compared to 8.1% in those without either factor (p < 0.001), indicating a synergistic effect. No significant differences were found in catheter removal time or hospital stay. Conclusions: Prostate cancer-particularly when known preoperatively-is associated with a significantly increased risk of bleeding during and after HoLEP, even when controlling for baseline characteristics. Surgeons should anticipate increased vascularity and plan perioperative management accordingly to mitigate haemorrhagic complications.